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In this feasibility study on prehospital sonography, our aim was to investigate the accuracy of TCCS for neurovascular emergency diagnostics when performed in a prehospital setting using mobile ultrasound equipment as part of a neurological examination. Methods: Following a stroke code call, stroke neurologists experienced in TCCS rendezvoused with the paramedic team.
In patients with suspected stroke, TCCS examination including ultrasound contrast agents was performed. Results were compared with neurovascular imaging CTA, MRA and the final discharge diagnosis from standard patient-centered stroke care. Results: We enrolled stroke code patients with follow-up data available in patients with complete TCCS examination. A diagnosis of ischemic stroke was made in 73 cases; 29 patients were identified as stroke mimics.
Conclusions: The study demonstrates the feasibility and high diagnostic accuracy of emergency transcranial ultrasound assessment combined with neurological examinations for major ischemic stroke. Future combination with telemedical support, point-of-care analysis of blood serum markers, and probability algorithms of prehospital stroke diagnosis including ultrasound may help to speed up stroke treatment. Keywords: Acute stroke; Emergency medicine; Prehospital diagnostics; Transcranial neurosonography; Mobile health unit Background Ischemic stroke is a time-critical vascular disease that affects neural function and is the leading cause of permanent disability in people in industrialized nations [1,2].
Significant prehospital delays are the main reason why patients do not receive effective treatment [2,7,8]. Recent analyses from previous studies demonstrate a total median prehospital delay varying between 35 and 71 min [9,10]. Ideally, this time period may be devoted for diagnostics, early allocation to an appropriate hospital, and initiation of stroke-specific therapies  Herzberg et al. This is an open access article distributed under the terms of the Creative Commons Attribution License which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Critical Ultrasound Journal , Page 2 of 13 Transcranial color-coded sonography TCCS is a feasible, fast, and non-invasive bedside method for the evaluation of cerebral arteries in acute stroke, and it is a routine tool in most stroke units. Particularly when contrast agents are applied, TCCS is valid compared with computed tomography CT angiography  and magnetic resonance angiography MRA  for the diagnosis of arterial occlusions in patients with acute ischemic stroke, especially in middle cerebral artery MCA obstructions .
Assessment of vascular pathology and hemodynamics in patients with acute stroke is thought to enable early judgment of functional outcome and thrombolytic efficacy and could identify patients who might benefit from interventional treatment . In our study, we focused TCCS examination on the detection of middle cerebral artery occlusion in its proximal segment M1- MCA occlusions - the most common site for cerebral artery occlusions - since we hope to shorten time from symptom onset to beginning of therapy with a very early diagnostic approach.
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Goal of this investigation In this Regensburg stroke mobile project, wehypothesized that a neurologist equipped with a portable ultrasound device is able to achieve a similar diagnostic accuracy in the field as compared with in-hospital advanced neuroimaging CTA, MRA. Methods Study design We describe a single-site prospective study in which we compare the results of preclinical neurological examinations supported by TCCS in the field with the results of standard stroke imaging studies CTA, MRA and with final discharge diagnoses from the treating stroke unit.
In the hospital, standard stroke care was applied without a dedicated imaging or treatment algorithm. In this regard, prehospital TCCS was performed to confirm or deny the presence of major intracranial artery occlusions and not to detect intracranial hemorrhage. Despite the non-invasive nature of the study, we obtained written informed consent from the patient or the next available relative.
The study was approved by the local ethics committee Ethic committee Nr.
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Setting The diagnostic portion of the study was performed between May and January in the city and rural district of Regensburg. This region supports a population of approximately , people in east Bavaria, Germany; the operational area that we covered extended up to 35 km in radius Figure 1. Selection of participants Patient enrollment took place during regular work hours 8 a. Patients were enrolled consecutively and unselected by the dispatch center.
The dispatch center did not follow dedicated inclusion criteria but decided following its internal routine algorithms. After the dispatch center received a stroke call the German equivalent for a stroke call in the USA , the ambulance team emergency physician and paramedic and the stroke team a stroke- and TCCSexperienced neurologist and a paramedic driver in a BMW series 1, dedicated stroke mobile were both alerted and sent to the site of the incident.
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After first aid had been provided to the patient and vital parameters had been stabilized, a brief neurological examination was performed. In such cases or if the patient did not show any neurological symptoms, patients either stayed at home or were transferred to the nearest emergency medical department. These cases were not included in the study follow-up. All patients who presented symptoms indicating probable or definite acute stroke were included in this analysis. Interventions In all patients with symptoms of an acute stroke, neurological examination was immediately followed by a TCCS assessment.
Neurological examination was based on a simplified and structured assessment including paresis in face, arm, and leg; speech disorders; consciousness; and gaze palsy.
Symptoms indicating probable or definite acute stroke were defined as one positive symptom with acute onset. Additionally acute stroke was proposed if the neurologist had the suspicion of stroke due to symptoms like dizziness, hemianopia, and related symptoms. The highest priority in all cases was to avoid any delay before hospital admittance. Ultrasound examination took place either at the site of the initial treatment for example, at the patient's couch, on the floor, or at bedside or during ambulance transport.
All neurological patients were transferred to a specialized stroke unit. The primary vascular diagnostic method was chosen based on the patient's level of consciousness, comorbidities for example, a cardiac pacemaker was a contraindication for magnetic resonance imaging MRI , and severity of symptoms. The final diagnosis was made by the responsible stroke team neurologist based on all available clinical information and the contents of the.